M+O 9 - TMDs Flashcards
What are temporomandibular disorders (TMDs)?
a group of conditions affecting the temporomandibular joint and/or the muscles of mastication
What is the prevalence of TMD?
10-15% of population
Are TMD more common in males or females?
F>M
When is the peak incidence age range for TMD?
18-44 years old
What is the aetiology of TMD?
multifactorial:
- biological
- psychological
- behaviour
biopsychosocial
What underpins the way in which we understand and manage TMD?
the biopsychosocial model of pain
When taking a TMD history, what needs to be asked about?
- pain
- noises
- movement
- habits
- trauma
- co-morbidities
What needs to be asked about ‘pain’ during history taking?
- character
- site : jaw, ear, in front of ear, temple
- affected by: jaw movement, function, parafunction
When might patients experiment TMD pain?
Some patients may be pain free apart from in function, other patients may experience persistent background aching pain/soreness which is exacerbated in function.
Less commonly patients may experience a sharp short-lived pain on jaw movement
Where may the pain in TMD be located?
Depending on whether the joint, muscles or both are involved, the pain may be localised to area of TMJ radiating up to the temple and down along the lower jaw and along the maxilla from this site, or may be more focused in the region of the temporalis and/or masseter muscle
When would be normally expect TMD pain to be exacerbated?
- on eating (particularly foods that are hard, crunchy or chewy)
- on attempted wide mouth opening
- also likely to be exacerbated by habits such as chewing gum or grinding/clenching of the teeth
What needs to be covered about ‘noises’ during history taking?
- type of noise heard
- on jaw movement?
- in past 30 days?: would normally expect patient to have experienced them in the 30 days prior to the appointment
- any previous noises which have now ceased
What noises are usually indicative of a disc displacement?
clicking, snapping, or popping sensation
What is crepitus indicative of?
degenerative changes affecting the TMJ
Why is it significant if the patient has a history of previous clicking which has now stopped?
if the clicking has stopped and left the patient with restricted mouth opening, this can indicate an anterior disc displacement without reduction
What needs to be asked about ‘movement’ during history taking?
- restricted opening
- interfering with ability to eat?
- locking - intermittent/persistent; closed; open; able to release with manoeuvre?
- deviation
What does deviation of the jaw to one side usually indicate?
usually an indication that the side to which the mandible is deviating, the condyle is rotating but not translating, so movement is restricted on the side to which the jaw deviates
- Particularly mentioned when it interferes with eating
What is an open lock?
condyle lies anterior to the articular eminence, rarely able to be released by manoeuvre (like in a dislocated jaw)
What do you need to ask about ‘habits’ during history taking?
- clenching
- grinding
- chewing or biting habits
- musical instruments
- singing
What do you need to ask about ‘trauma’ during history taking?
past history
What are the ‘co-morbidities’ to ask about during history taking?
- fibromyalgia
- chronic pain
- psychological factors
What psychological factors may play a role in TMD?
- stress, anxiety, depression
- pain may be exacerbated in times of stress, may be associated with para function all habits like tooth clenching or grinding
What do you need to assess during a TMJ examination?
- palpation of TMJ
- palpation of muscles
- mouth opening
- intra-oral soft tissues
What do you need to do during palpation of lateral pole of TMJ?
- stand behind patient, locate TMJ, ask patient to open and close mouth
- place fingers direct over the joint and apply gentle pressure to one side and then the other, asking the patient if there’s any pain or tenderness
- ask the patient to open and close their mouth three times
During palpation of TMJ what should you be asking the patient to report?
- any pain or discomfort they experience
- is it the pain they normally experience?
- any noises (these may also be audible to you)
What movements should you get the patient to do 3 repositions of during palpation of TMJ?
- opening
- closing
- lateral
- protrusive
What muscles should be palpated during TMD exam?
temporalis and masseter
What should you be asking the patient to report during palpation of muscles?
does the palpation elicit the patient’s familiar pain?
How do you palpate the temporalis?
- palpate when teeth clenched
- above the ear and forwards above the eye
- palpate each side in turn
How do you palpate the masseter?
- biannual palpation
- two fingers inside patient’s cheek, two fingers outside the patient’s cheek
- ask patient to clench teeth together to make sure you’ve located the masseter muscle accurately
- ask patient to open their mouth slightly to relax the muscle and then palpate at origin, midpoint and insertion
- while palpating, ask patient to tell you where they experience pain, and if it is their familiar pain
What should you assess about mouth opening during TMD examination?
- deviation on opening
- extent of opening - unassisted and assisted
What kinds of deviation on opening may a patient have?
- may be a sustained deviation to one side or…
- the patient may have a sinusoidal path of opening where the lower jaw deviates to one side and then swings back into the normal central position and opening continues.
- in some patients you may detect a click at the point where the jaw begins to swing back into its normal central position
What do you use to measure extent of opening?
a ruler
- would normally record max. unassisted, and max. assisted opening
How do you carry out assisted opening?
place 2 fingers between the patient’s upper and lower teeth and gently and gradually try to move their upper and lower teeth apart
For mouth opening, what is the key figure to remember?
40mm - including incisal overlap
What would you asses during intra-oral soft tissue examination of TMD?
- ridging buccal mucosa at level of occlusal plane
- scalloping of border of tongue
- toothwear
What is ridging of the buccal mucosa at the level of the occlusal plane suggestive of?
an active parafunctional habit such as clenching, grinding or tongue thrusting
Why is it more difficult to assess significance of tooth wear?
to determine whether this is historical or ongoing you would have to take impressions and cast models at intervals
What TMD investigations can be done?
- plain radiographs not normally indicated
- Cone Beam Computed Tomography (CBCT)
- Magnetic Resonance Imaging (MRI)
If degenerative changes are suggested, what investigation might be appropriate?
CBCT of TMJs
If displacement is suggested, what investigation might be useful?
MRI - particularly if a disc displacement without reduction is suspected. This will also pick up any degenerative changes affecting the disc or the bones of the joint
What are the 2 main categories of TMD diagnoses?
- pain related TMDs
- intra-articular TMDs
What are the 2 categories of pain related TMDs?
- myalgia: relates to muscle pain
- arthralgia: related to joint pain
What are the 3 types of myalgia diagnoses?
- local myalgia
- myofascial myalgia
- myofascial myalgia with referral
What can arthralgia cause?
headache related to TMD
What are the types of intra-articular TMDs?
- disc displacement with reduction
- disc displacement with reduction with intermittent locking
- disc displacement without reduction with limited opening
- disc displacement without reduction without limited opening
- degenerative joint disease
- subluxation
What does disc displacement with reduction present with?
a clicking jaw joint
What is disc displacement without reduction with limited opening characterised by?
history of previous clicking, which stops at the same time as the onset of restricted mouth opening
What does subluxation present as?
an open lock
What are the 3 TMD classification criteria?
- description
- history
- examination
What is the ‘description’ of myalgia?
- pain of muscle origin, affected by jaw movement, function or parafunction
and - replication of this pain on provocation testing of the masticatory muscles
What is the ‘history’ of myalgia?
- pain in jaw, temple, in front of the ear or in the ear
and - modified with jaw movement, function or parafunction
What is the ‘examination’ of myalgia?
- confirmation of pain location(s) in the temporalis or masseter muscle
and - familiar pain in masseter or temporalis muscle with at least one of the following provocation tests:
- palpation of temporalis or masseter muscle
or - maximum unassisted or assisted opening movements
- palpation of temporalis or masseter muscle
What is local myalgia?
pain localised to the site of palpation
What is myofascial myalgia?
pain extends beyond site of palpation but still within the boundaries of the muscle being palpated
What is myofascial pain with referral?
pain extends beyond the boundaries of the muscle being palpated
What is the ‘description’ of arthralgia?
pain of joint origin affected by jaw movement, function or parafunction and replicated by provocation testing of the TMJ
What is the ‘history’ of arthralgia?
- pain in the jaw, temple, ear or in front of the ear in the past month
and - pain modified with jaw movement, function and parafunction
What is the ‘examination’ of arthralgia?
- confirmation of pain location in area of TMJ(s)
and - familiar pain: on palpation of lateral pole
or - on maximum unassisted or assisted opening, right or left lateral or protrusive movements
What is the ‘description’ of disc displacement with reduction?
- intra capsula biomechanical disorder involving the condyle-disc complex
- in the closed mouth position the disc is in an anterior position relative to the condylar head and the disc reduces on mouth opening
- clicking, popping, snapping noises may occur with disc reduction
What is the ‘history’ of disc displacement with reduction?
- history of ‘noise’ in past 30 days in movement/function
or - patient report of any noise during examination
What is the ‘examination’ of disc displacement with reduction?
- clicking, popping, and/or snapping during opening and closing movements on palpation
or - clicking, popping, and/or snapping during opening or closing movements on palpation
and - clicking, popping, and/or snapping during left or right lateral protrusive movements
(all in at least 1/3 movements)
What is the ‘description’ of disc displacement without reduction with limited opening?
- the disc does not reduce with opening
- persistent limited mandibular movement which does not reduce when the patient or clincian performs a manoeuvre
- closed lock
What is the ‘history’ of disc displacement without reduction with limited opening?
- jaw locked so that the mouth would not open all the way
- limitation in jaw opening significant to limit jaw opening and interfere with ability to eat
What is the ‘examination’ of disc displacement without reduction with limited opening?
maximum assisted opening (passive stretch) movement <40mm including vertical incisal overlap
What is the ‘description’ of degenerative joint disease?
a degenerative disorder involving the joint characterised by deterioration of articular tissue with concomitant osseous changes in the condyle and/or articular eminence
What is the ‘history’ or degenerative joint disease?
- history of ‘noise’ in past 30 days on jaw movement or function
or - patient report of any noise during examination
What is the ‘examination’ or degenerative joint disease?
crepitus detected with palpation during at least one of the following:
- opening
- closing
- right or left lateral movements
- protrusive movements
What is degenerative joint disease in the absence of pain termed?
osteoarthrosis
What is degenerative joint disease accompanied by arthralgia termed?
osteoarthritis
What is the ‘description’ of subluxation (open lock)?
- a hypermobility disorder involving the disc condyle complex and the articular eminence
- the disc condyle complex lie anterior to the articular eminence and cannot be returned to a normal closed position without a manipulative manoeuver
- may be momentary or prolonged
What is the ‘history’ or subluxation (open lock)?
- in the last 30 days jaw locking or catching in a wide mouth open position, even for a moment, so could not close from the wide-open position
and - inability to close the mouth from a wide-open position without a manipulative manoeuver
What is the ‘examination’ of subluxation (open lock)?
no examination findings required but if disorder present at time of clinical examination then:
- inability to return to a normal closed mouth position from a wide open position without the patient performing a manipulative manoeuver
What is the initial management of TMD in primary care?
- reversible and conservative
- explanation (condition and management)
- advice focusing on self-management (and home physiotherapy)
- analgesia (only prescribe when necessary)
What are conservative management strategies for TMD?
- rest and relaxation
- modify diet
- avoid wide mouth opening
- regular application of gentle heat (chronic conditions)
- regular application of cold pack (acute onset pain &/or restricted mouth opening)
- jaw exercises
- NSAIDs (e.g. ibuprofen if not contraindicated 14 day course)
What would be prescribed for muscle spasm or disc displacement without reduction with limited opening?
diazepam 5 day crouse (unless contra-indicated)
- prescribed as a muscle relaxant
What diet modifications can help manage TMD?
- advise the cease any biting/chewing habits
- avoid chewy, hard, crunchy foods
- cut food into smaller pieces
When would you refer a TMD patient to a specialist?
- chronic TMD symptoms lasting >3 months
- persistent or worsening symptoms despite primary care treatment
- an uncertain diagnosis
- marked psychological distress associated with symptoms and/or occlusal preoccupation
- unexplained persistent pain or chronic widespread pain
What anagram can tell us what patients may be at risk of developing chronic symptoms and for whom referral is appropriate?
FLATS
F - fear of pain
L - low mood
A - avoidance of functional activities
T - thinking the worst
S - social impact (TMD is having a negative impact on patient’s interaction with others)
